All right. Good afternoon. We'll go ahead and get started. Thank you so much for joining us this afternoon. I know there's so much to see and do at this conference, and as much fun as we have, it can also be a little exhausting. So we really appreciate you joining us this afternoon for this session titled Refilling Our Cups, Total Worker Health Systems Level Programs to Improve Community Health Center Staff Well-Being. I'm Dr. Rosandra Day Walker. I am an Occupational and Environmental Medicine Physician, and I am also a CDC NIOSH Total Worker Health Doctoral Trainee. I'm based out of Houston. And I'm Dr. Mark Day Walker. I am the Director of Health and Well-Being at Access Health Community Health Centers. So we have no financial disclosures or conflicts of interest at this time, and these views and opinions are ours and ours alone. So I want you for a moment to close your eyes, and I want you to imagine. Imagine the worst job you've ever had or the worst day at work or worst week at work you've ever had. Okay? What was it about that job or that day or that week that was so horrible? What was it about the culture, about the environment, about the relationships, the social environment, the workload that made it so horrible? Okay. Open your eyes. Now I'm going to ask you to close your eyes again. This time I want you to think about the best job you've ever had or the best day at work you've ever had or best week. What did that feel like? What was that culture, that environment like? What were the relationships at work like? What was the workload, the autonomy? What made that so good and fulfilling? It made you want to come back the next day. So for a lot of people, you can open your eyes. I want you to keep those two memories juxtaposed. For a lot of people, the last two years have been the worst of their lives. So this is the story about how some of us got together and tried to make it a little bit better for some of us working the front lines and how we ended up achieving some pretty amazing results. So we'll just start with what happened, what outcomes did we have, followed by how did we do it, and then finally why we think it worked. So to give you a little bit of background, Access Health is a federally qualified community health center about 40 minutes outside of Houston that serves populations with limited access to health care, including low income populations, those on Medicaid, as well as the uninsured, people who might have limited English proficiency, migrant and seasonal farm workers, individuals and families experiencing homelessness and more. And so as a very affordable option, Access Health is most times people's only access to health care. Before COVID, most community health centers like Access Health were already overwhelmed and under resourced. These issues, combined with the emotional and psychological toll of taking care of vulnerable populations day in and day out, played a significant role in high turnover rates historically. And then COVID, right? COVID exponentially compounded these issues and brought about several new ones. So seeing a need to track and possibly intervene in the well-being of the staff at Access Health and other community health centers, the Texas Association of Community Health Centers, or TAC for short, which oversees all of the community health centers in Texas, administered a new health and well-being survey to the staff of about 40 different centers. The baseline was taken in August 2020, about five months into the first lockdown in COVID in the US. And then we had a follow up one year later, in July 2021. Everything that was going on portended that we should be expecting some, you know, overwhelming burnout, which is what healthcare workers globally were experiencing, right? But oddly, we saw improvements in employees' overall well-being, in compassion fatigue, in burnout, in gratitude, positive supervisor relationships, and the sentiment that the organization listens to and addresses worker concerns. So what was going on? Were these staff at Access Health somehow superhumanly resilient and immune to the effects of the strain and suffering brought about by COVID? Or was something else at play? Well, something else indeed was at play. After all, burnout is a work-related phenomenon. So something about the workplace was either protecting or even enhancing their well-being, which brings me to how we did it. So first, I'll briefly cover how we measured those outcomes, what kind of measures we used, and then follow it up with a discussion about the organizational transformation and programming that actually occurred between that baseline survey and that follow up. So I personally got involved with this work when my husband was saying that he needed to come up with some kind of survey to track the health and well-being at the health center. And because I was a Ph.D. or still am a Ph.D. student at the time, something like this was certainly in my wheelhouse and healthcare worker well-being is something that I'm already passionate about, so I volunteered to design it. In the end, it consisted of several, a few different validated open source measures such as the World Health Organization Well-Being Index, the Professional Quality of Life Scale, the Gratitude Adjective Checklist, and then a few original questions about the workplace psychosocial environment and questions about coping and assistance. At the end of this, creating this survey, the TAC, or the Texas Association Team, loved it so much they actually ended up using it to run an assessment on 42 other community health centers in Texas. So, the World Health Organization Well-Being Index, or the WHO-5, is a short self-reported measure of current mental well-being that consists of five statements which respondents rate according to the scale below in relation to the past two weeks. So it asks questions about feelings of cheerfulness, good spirits, feeling calm, feeling relaxed, feeling fresh, rested, active, vigorous, and, of course, the last one, my daily life has been filled with things that interest me. The Professional Quality of Life Scale, or the PRO-QOL, is a 30-item self-report measure of the positive and negative aspects of caring professional work, okay? And it is consisted of two main dimensions, which is compassion satisfaction and compassion fatigue. And then compassion fatigue is further broken down into two sub-dimensions, burnout, dun-dun-dun, and secondary trauma, which we'll talk about a little bit more when we talk about trauma-informed care. It starts with a statement, a prompt, that asks people to think about when they are helping people, that they come into direct contact with their lives, and how they may find that their compassion for those that they help can affect them in positive and negative ways. And then there's some statements that they are asked to rate for their experience over the last 30 days, feelings such as I am happy, I get satisfaction from being able to help, I jump or I'm startled by unexpected sounds. So it's looking at sort of both sides of the pendulum there. And there are different versions depending on the profession that you're interested in investigating, and so we used one that was adapted to the healthcare professions. The gratitude adjective checklist. We measured gratitude or we were interested in gratitude because it is another factor that is empirically related to well-being and positive psychology. So it asks the respondents to indicate their level of feeling the following over the past few weeks. Grateful, which is feeling or showing appreciation for something done or received. Thankful, feeling pleased and relieved. And appreciative, recognizing the worth of something or someone. And so that is what that scale looks like. Then we got to the questions about the workplace psychosocial environment, and these were original questions that we came up with to investigate the staff's sentiment regarding supervisor relations and being heard by leadership. So we asked them to rate their level of agreement on the following statements. I feel comfortable talking to my supervisors about my concerns. I feel like my organization listens and addresses my concerns well. And as you know, there are direct relationships again with that supervisor relationship, supervisor interactions, and how the organization listens or hears their workers and actually responds. And well-being and productivity and engagement. Finally, we asked about coping and assistance to give us an idea about what kind of coping mechanisms our staff were using and what areas that we could help or what additional resources we could provide that they actually would want or be interested in to help them during this time. So the first one was, which coping strategies have you employed? And so some of the choices included things like professional counseling, exercise, spending time with loved ones, avoiding distressing thoughts, or even substance use. And the way we structured this survey in terms of what demographic information we pulled, we were very careful not to utilize any questions that could potentially identify respondents. So the demographics we took were very, very nonspecific and very limited. Again, so we could protect people. We didn't want people to feel like, you know, something potentially could be revealed about them that they would rather, you know, folks not know. And then this was, which coping strategies, I'm sorry, what assistance, resources, or information would help you at this time? So things like, could we offer more work time place flexibility? Could we offer more information about financial assistance programs? And then the actual data collection and analysis was performed by TAC and UT Health, UT Health Science Center in Houston. Now, the other Dr. Day-Walker will take over to describe what the, describe the actual organizational transformation and the activities and programs that took place, or that he implemented to prevent distress, to protect mental health, and to promote well-being. So thank you, Ro. So to give you guys a little, so to give you guys a little background, I was asked maybe one month after working at Access Health, if I would be interested in being a trauma-informed care trainer to lead our organizational transformation. And by the look on some of the faces in here, you guys had the same thought that I had. What the heck is trauma informed care, right? So at that time, when it was described to me, it was stated that TAC, or the Texas Association of Community Health Centers, put together this initiative to effectively respond to some of the marginalized populations that we were taking care of that were disproportionately affected by Hurricane Harvey. This immediate, immediately resonated with myself because my wife and I, we did residency out in Galveston, Texas, one of the places that was really hardest hit by Hurricane Harvey, and we took all the necessary precautions. We had at that time just bought a brand new car that we put up somewhere where we thought would be safe. We took my car that was more than 10 years old. We were like, we'll put the miles on this car and go to Dallas. So we got back to Galveston to learn that that brand new car was no more. It was flooded. We got back to Galveston to learn that our apartment had experienced severe water damage, so we actually had to relocate. And this was while in residency. So this mission immediately connected with me. Now, what I'll also say, although it immediately connected with me, it did not take away that visceral stress response that I had about trying to bring on something additional to my plate as a brand new attending physician that just finished residency. I had a patient panel that I was in, you know, that I had now the buck stopped with me in terms of taking care of these patients. I was working on the EHR, trying to figure out how to manage that. So I didn't immediately jump at this, but the bleeding heart that I am, I eventually had to say yes to it. So I signed on to do this thing, lead this organizational transformation, again, one month in, fresh out of residency. Needless to say, I had no idea that we would be experiencing the trauma, the traumatic experience that COVID-19 was just three months later. To fast forward a little bit, literally maybe two weeks after kind of learning about COVID-19, trying to figure out how we were going to respond to this thing, I was actually in the meeting with my CEO and his truly empathetic response to wanting to support our patients, our staff at this time, didn't want to furlough anyone. It really was compelling and it allowed me to like send him an email and say, hey, I think that we have this trauma-informed care thing that we may be able to leverage and shift the focus a little bit from maybe the patient perspective and placing on the employees to kind of help them with this challenging time. And after a few different discussions with him, he finally agreed and we became the only health center to move forward with the trauma-informed care transformation. And we started to become the pilot for everyone to follow afterward. So we were very fortunate that we had already started this transformation going through the process of making sure that our policy, our procedures, our practices was embedded with these core tenets of trauma-informed care, which are safety, trust, choice, empowerment, collaboration, and respect. And I think this is what led us to have really profound results that we talked about at the beginning of this presentation. So after having several discussions with leadership, we developed a very simple health and well-being strategy. Literally, our overarching goal was just to support employees during the COVID-19 pandemic. Our strategic aims were to just to build trust, increase mutual support, strengthen interprofessional and cross-sector collaboration, with specific objectives to really increase workplace morale, decrease our staff's burnout, and strengthen our supervisors' and employee relations. So we knew that the elephant in the room was going to be burnout. So as a clinician, I was particularly concerned because with the onset of COVID-19, we had a dramatic increase of people being diagnosed with affective disorders like anxiety, depression, and not to mention the primary, secondary, and vicarious traumas that came along with the pandemic. So naturally, I consulted my local total worker health expert to help us figure out what type of framework we could utilize or leverage to address burnout. So I really wanted to reinforce here that burnout is an organizational issue, not just an employee cause to why we're experiencing burnout maybe at work. So we will further discuss this topic using the framework from the burnout epidemic written by Jennifer Moss, and she lists the organizational factors as values mismatched, perceived lack of control, workload, poor relationships, lack of fairness, and lack of recognition and reward. So after the start of the pandemic, there was a strong sense of panic and fear about coming back to work, especially in the health care setting. To address this mismatch of values, we knew that our messaging needed to align with our actions. So, we wanted to really make sure that our staff felt both physically and psychologically safe. We started with leadership buy-in, which included both engagement and budgeting to make sure that we have resources available to fund the interventions. Our CEO was very creative in creating this new director of health and well-being position that solely focused on the health and well-being of our employees. Who was that? That was me. And we also were very thoughtful and intentional about sharing into the personal stories that our staff was sharing with us. So, I was able to convince my CEO, as well as my fellow trauma-informed care trainers to write a COVID-19 trauma-informed newsletter just to let everyone know that, hey, we're experiencing this right along with you. And I think most importantly, the most important thing that we could have done was ask. And that's what we did. We asked our employees, how could we support you during this challenging time? So, to address the perceived lack of control, we created an anonymous feedback tool with the responses sent directly to myself, as well as the CEO. This means that a front desk staff person, this means that someone doing landscaping had a direct line to our CEO about anything that they wanted to address with him at this time. So, this helped give back a sense of empowerment and autonomy to our staff, assuring that their needs would at least be heard. And the CEO and I met biweekly to address the reoccurring themes that we started to notice, actually, in the feedback. We found that there was some fear and panic around the COVID pandemic and the unknowns, which led to multiple town hall meetings to address COVID-19. There was a lot of misinformation, if you guys can remember back to the start of the pandemic, as well as different things about safety and efficacy of the vaccinations. So, that was two town halls we had. We also learned through our suggestion box that we had several inefficient operational processes that had been long ignored, and that there was a need to modify our processes due to COVID. To address these issues, our COO, our chief operations officer, modified several operations regarding front desk and our referral processes. We also decreased the emphasis on productivity during this time. Through our feedback, we also found multiple complaints of unfair treatment by supervisors or managers, and this build of the us versus them mentality amongst staff. A lot of you probably can vividly go back and remember that during this time, especially in healthcare, we had administrators that did not, well, they had the opportunity to work from home, whereas people that were on the front lines of things had to come in and go to work. And this kind of led to some disdain across that particular sector. So, to address the lack of fairness, here, the executive leadership met with the middle management staff to remedy these issues, but unfortunately, it was met with some blaming of our support, some of their subordinates, and resistance to correcting their behaviors, which led to the resignation of two different supervisors. The us versus them mentality seemingly dissipated after our town hall to help staff address their experiences of the Texas winter storm of 2021, and I thank you. Yes, which was a very particularly traumatic time. I don't know how many of you are in Texas or heard back in 2021 in February when we had that big winter storm and many were left for days with no electricity and below freezing temperatures, no running water, no heat, couldn't leave the house. And we were one of those people with a six month old at the time. And so, it was definitely traumatic for everyone involved. People really suffered on top of still being in the midst of COVID. And yeah, some people even lost their lives. So, this was a great opportunity to come together and help each other process it. So, to address the poor relationships, we created an employee buddy system to help combat the geographic separation as well as the social distancing and loneliness during this time to help strengthen relationships. For this matching process, we crossed employees within different departments with similar interests to strengthen the peer support across the organization. The levels of engagement here with their buddies was really employee driven. We did encourage the use of a COVID-19 coach app, but their levels of engagement and what they wanted to share to support each other was left up to the buddies. So, globally, we knew that people's well-being were suffering. That was a no brainer. We knew that our staff would be no different if we didn't act swiftly. So, we created a hero building campaign that mirrored much of the messaging around the frontline health workers being heroes, healthcare heroes. And within this campaign, we sought to increase psychoeducation through town halls, provide self-care strategies and wellness initiatives with each carrying incentives and rewards. So, hero building is actually based on Dr. Fred Luthen's work on positive psychological capital and the hero model. Psychological capital is characterized by high levels of hope, efficacy, resilience, and optimism, which are the four letters that make up the word hero, the acronym HERO, which we sought to strategically anchor our interventions within because we knew that increasing or building through this concept would increase happiness, which is essentially well-being, as well as possibly increasing employee performance. The final intervention that I wish to share with you all is our Well at Work program, where we partner with Mindcare Solutions, a tele-psych organization. They provided free therapy sessions for our staff and their spouses, in addition to giving us mental health town hall meetings. So, in conclusion, what I gathered from these different interventions and partnerships, I believe that our trauma-informed care transformation really provided that framework to allow for the culture to be sufficient to allow us to actually address burnout and our hero building to address well-being. So, to answer that question that still kind of remains is why did it work? And I'll pass it over to Ra. Thank you. So, yeah, why did it work? Or why do we think it worked? So, you're probably thinking, in the middle of COVID, how the heck did you do all of that? Right? We were barely surviving. This is true. Which brings to mind the saying, if you want to go fast, go alone. If you want to go far, go together. We accomplished so much largely because of the support and guidance that we had and the collaborations and partnerships. So, the support and guidance from the Texas Association of Community Health Centers, we really leveraged that. It took advantage of all of the resources and guidance that they had to offer. And they also led the organization through that trauma-informed care transformation. We collaborated with UT Health, who conducted the data collection and analysis. Right? Because if you remember, it's a community health center, not a lot of resources, not a lot of personnel, and probably not a fancy dashboard, but maybe one day. And then partnered with Mindcare, who was funded by, again, a grant from Texas Association of Community Health Centers to provide that much-needed resource for the employees. Then, there were also the paradigms that formed the foundation and the inspiration for the activities and programs that we designed, including Total Worker Health, trauma-informed care, and lifestyle medicine. So, Total Worker Health, we're at an occupational and environmental medicine conference. It's probably on the tip of everyone's tongues, as it's gaining traction nationally and internationally. And I'm personally wrapping up my PhD in this topic. So, yesterday, Dr. Jung's wonderful and engaging lecture really had me feeling validated about my multiple terminal decrees. But Total Worker Health comes from NIOSH, which defines it as policies, programs, and practices that seek to integrate protection from work-related safety and health hazards with the promotion of injury and illness prevention to truly advance and optimize worker well-being. You may recognize this image, in particular, as the hierarchy of controls. But this one is applied to Total Worker Health. Like the traditional hierarchy of controls, strategies are presented in order of expected effectiveness from top to bottom, with an emphasis on systems-level, environmental, and organizational strategies. So, in our work, rather than starting with the employee and saying, hey, you need to be more resilient, which, honestly, staff working in a community health center are probably as resilient as they get. But instead, we started by looking at what the organization and the leadership was doing and could be doing better. We weren't gonna tell people in a burning building to drink more water, okay? We were gonna put the fire out and hopefully prevent more fires from happening. And then, some of you, wink, wink, I see you. Some of you may remember our session from last year at AOHC 2021 on trauma-informed care for occupational medicine. Well, we're back. We're back again. You can't get rid of us. And we're gonna keep talking about trauma-informed care to anyone who will listen. But it comes from the Substance Abuse and Mental Health Services Administration. And it's based on the landmark ACES, or Adverse Childhood Experiences, study that took place about a decade ago that identified the link between psychologically traumatic experiences and long-term chronic health problems, mental health problems, substance abuse, difficulties in school and work performance, and more. Pre-pandemic, it was estimated that at least 70% of US adults had been exposed to a potentially traumatic event in their lifetime. Where do you think we're at now? So, the benefits of this paradigm are twofold. It helps create psychological and physical safety, empowering environments for your patients and clients, but it also protects us, the clinicians and staff that are taking care of these patients and clients. Protects us from burnout and vicarious or secondary trauma, because us healthcare heroes are human, too. We face our own traumas, and we often take on the traumas of others. Finally, we drew from Lifestyle Medicine, which is another interest of ours together, which focuses on six key areas to improve health. And by the way, there's actually a concurrent session going on right now about Lifestyle Medicine, which focuses on, and I actually work with the people in a Lifestyle Medicine in the Workplace work group who are hosting that session. But anyway, it focuses on six key areas to improve health, including healthful eating, physical activity, sleep, and avoiding risky substances. It's simple, right? But somewhere along the line, we kind of lost focus on that in our healthcare system. The two pillars that inspired our work was, one, developing strategies to manage stress, and two, leveraging the power of social connectedness by forming and maintaining positive relationships. At the end of the day, the numbers and data are really nice. You know, we started with those results at the beginning so we could get that out of the way so that you would believe us. But really, these are real impacts that we had on real people. This is some of the feedback that my husband, Mark, actually got from people throughout this process. One person said, I have implemented a self-care plan to ensure that I have wellness physically and mentally. Another one said, AccessHealth truly is a trendsetter by finding innovative ways to maintain an inclusive, safe, and empowering environment for staff, patients, and local communities we serve. Finally, someone else mentioned, all of us are hurting, and we are so used to sweeping all feelings aside and getting back to business as usual. When a person feels heard, understood, and has leadership they can look up to and respect, it definitely affects productivity in a positive way. So, if you take anything from this, you can take the importance of collaboration, of transforming and creating a culture and an environment that supports wellbeing, and making sure that people feel heard. When people feel heard, truly listened to, they feel valued, they feel respected, they feel cared for, right? And guess what? It also helps your bottom line, because there are associations between employees feeling heard and engagement and productivity in the workplace. So, in conclusion, think about how to connect with each other, how to show respect for each other, and how to protect each other in these times. As carers and caring professions like we all are, we tend to pour and pour and pour from our cups to help others, and now we have a chance to refill our own cups and reclaim our humanity. So, thank you. And so, now, these are just some additional resources to explore that will be included in the slides, and we'd love to open the floor up to questions, comments, discussion, anything we wanna hear from you. Yes? Thank you for your wonderful presentation, and I hope you have all been well, and you've been well through it. Thank you. When you guys took your surveys out, you sent all those questions out to your one clinic, or to all of AccessHealth? Okay, so, from what I remember, because UT Health did the actual collection at the time, along with TAC, so I wasn't privy to everything, but, yes, they sent it to, so AccessHealth itself has multiple sites. How many sites? 12 sites. 12 sites, including clinical centers and WIC offices. So, yes, all the 240-plus employees did receive it, as did, I think, some other, the other centers that were also part of this trauma-informed care cohort. So, if you can talk about the response rate, it'd be very curious for me, because I have a hard time getting three questions back. I think you know more about that than me. So, it was sent to providers also? Just so we know. Sorry. Did it go to doctors? Yep. And practitioners and ADPs, as well? Was that survey? Yes, it went to all the staff. Yeah, and just to add there a little bit, so to give you a little bit more backstory, so early on when the CEO and I were meeting, we wanted to have some kind of formal tool to kind of see and measure if we had a real impact, right? So, I spoke to my wife about it, and we created a survey, and that survey, and my wife was working with the UT Health research team at that time, and that survey went to the overarching organization, TAC, the Texas Association of Community Health Center. It went to them, and they disseminated it to all of the participating health centers under their umbrella. This went to the organizations that had trauma-informed care as well as didn't have trauma-informed care, and yes, it was sent out to everyone that was affiliated, that was an employee for those health centers. And what response rate? So, yeah, I don't have, I actually, I have access to that data. I haven't looked at specifically that data, but we had a very high response rate. Yeah, I think it was 80% plus, but you guys did a lot of encouragement. If I remember, there was a lot of reminders. I think two people wanted to be heard in that time, I think, and also they made time available. I think that was the special thing you did. The clinic made time for people to sit down and fill it out so it wasn't like you were trying to do it on your own time and at home while you're trying to eat or feed your baby. So there was time actually carved out in the workday, and it took about, I think, 15 minutes. So it actually went a little bit faster than you might expect. Yes? How long did you have the survey open? I think it was a two-week period. Yeah, yeah, and it was a hard kind of close to it as well. Two weeks. So our CEO really helped champion a lot of this stuff. We spoke with supervisors, directors, and said, hey, we need to give time to our employees to actually complete this. They're doing it on the clock, so they felt incentivized in that way. We actually had other measures that we're looking at, like completion rate, that kind of triggered some of the rewards, incentives around some of these things. When you opened up the lines of communication between you and the CEO, the staff, were there unintended consequences, like the supervisors feel like people are going over their head, things that were just dumped on? How did you navigate that? I'm glad you asked that. Those conversations with the CEO were very interesting, right? But he was very open to the idea of wanting to help every which way that we could. I was already aware of some internal issues that employees didn't necessarily feel safe going to HR because of retaliation. As you can imagine, at the highest levels of the organization, the CEO is thinking like, hey, some of these things shouldn't be coming up to me. They shouldn't be floated up to me, quite frankly. But when I shared with him, and I repeatedly shared with him, I said, hey, if we're going to do this thing, we really need to be all in for it so that you can really address some of the organizational hygiene issues, right, before you start to do all the bells and whistles here to make sure that people feel heard and we're actually recognizing what they need. So we got a lot of unintended feedback. The questions in that feedback suggestion was things that we were doing. What are some things that we're doing very well to support you during this time? What are some things that we could be doing better? And then lastly, we had a feedback box there that said it was like ask a doc, and it related to anything that you had questions about during the pandemic because of all the misinformation and things out there. You tailored it really nicely. You tailored it and didn't have it just for the benefit of us. Well, they could write what they wanted. So we got a lot of unintended stuff that we really had to address. So it wasn't all roses. They didn't just say, oh, you're doing a great job. We love you. Thank you. We're going to work here forever. Some people actually had some things to say. So that's why when you saw on the slide we had two resignations. I guess I can say this. It was immediately felt the impact of getting out some people that weren't necessarily treating other people very fairly and things like that. It lifted the spirits of the organization. And it goes back to, again, systemic issues. And if you can address those. Does this go back? So remember that hierarchy of controls. Eliminate. So some elimination had to happen. And it wasn't nice. When I saw that, the two supervisors, I also made me think was it the staff really that may have been problems with the supervisor trying to correct those problems? And it felt like that they had gone over their head. It's the dynamics. Right. And that gets to become very complex issues when you start to kind of dig into them. Yeah. Are you going to be doing a follow-up to see like a long-term, you know, to see if things are improving or are things better? The question was are you going to be doing another or a long-term follow-up to see how things trend, if things remain the same, get better, get worse? Yeah. Yeah. So really great question. So HRSA is planning on, and I'm not sure exactly when it's going to happen, but I'm actually a part of what they're calling, they haven't I guess maybe not officially released it just yet, but a task force to create an organizational resiliency toolkit, because they do plan on creating an annual health and wellness survey for underserved like community health centers and things like that. So that will be kind of the follow-up from there, because this was a very. Grassroots effort. Right, right, right. And it just happened to have some funding to come along with it at the same time. And for the question in the chat, will slides be available? Yes, they will be. Yes, they will be. We will upload them. We have time, so ask away. The lines of follow-up. You were the primary movers behind this. And always on an initiative like this, when the primary movers leave and go somewhere else, is it institutionalized yet? And is it really there yet where you know it's going to stick? Or if the CEO leaves and a new one comes in and you have to start all over teaching him again, what are you doing? Where are you at in that process? What's your plans? So the question was about institutional change and the stickiness of it. You know, is it sustainable? Like where are we in the process? Is it something that's sort of ingrained in the culture? Or is it something that might end, you know, with change in leadership or with people leaving? Excellent question, because that's always the goal, right? That sometimes is the goal with organizational transformation. We want it to last. So, again, going back to trauma-informed care, it has a really fantastic model, at least the way it was implemented, when it's implemented appropriately and properly. So the trauma-informed care organizational transformation, which sort of underpinned all of this work, it's something that takes place over a few years. So they're actually still in the process of doing it. He himself had to get trained for over a year to become a trauma-informed care trainer. So they employ a train-the-trainer model. They also recruit champions, and in his case in there, they recruited champions at all the sites and within all of the different departments. So it wasn't just resting on one person or one department to make sure that this cultural change, this organizational transformation continued or took place. And then, again, partnering with a supporting organization, being a part of a cohort, like they did with TAC and with the other health centers that were part. It wasn't just Access Health doing this alone. There were actually nine other centers, I believe, that were part of their cohort. So there's this network, this network. And then there was another cohort that came after that, and there was one cohort before that. So very important question. So it goes back to collaboration and not trying to stick it on one person's shoulders to be that one. And also leadership buy-in. You've got to get the funds, you've got to get the money, the resources to support it. Are you seeing any measurable improvements in your community's health? The question is, are you seeing any measurable improvements in your community's health? I'm glad you asked that. So TAC is actually, again, the Texas Association for Community Health Centers, that governing body is doing all of that analysis now. And they're doing that for all of the health centers. And they're even taking it one more step, because I was at their conference last week. They're getting really nuanced. Let's say, for example, in terms of asthma exacerbation, that's one thing that they shared at the conference, that they saw significant improvement in terms of asthma exacerbations for the health centers that adopted trauma-informed care, because their ethos is that if they can get staff to be truly trauma-informed, to be able to realize, first off, that psychological trauma exists, recognize that there are real tangible effects from psychological trauma, respond appropriately to those individuals that are displaying those signs, symptoms, and effects of trauma, and resist retraumatization, that that will have a profound effect to the patient's clinical outcomes as well. So they're actually collecting all of that data. I got a question, a couple of questions in the chat. The first one asked, are any of your employees unionized? I don't believe so, not in the community health center. Not that I know of. And I'm not sure if that is a community health center thing or just particular to Access Health or to Texas, but that is a really good question, right? Because that can have huge implications on a lot of things from how protected employees feel or their support system outside of the workplace, their leveraging power, et cetera. So that's a really good question. That would be really interesting to sort of look at, you know, if there is any work being done with trauma-informed care in unionized spaces. And then I have another comment. So we have a comment in the chat from someone in a community health center in Massachusetts who says that the HRSA toolkit for organizational resilience that Mark mentioned earlier is actually the first iterations have started rolling out because they received their first survey. So this is something real and big that, you know, thankfully we're finally looking at for, you know, what is essentially the safety net of the country when it comes to health care. Any other questions? Let me ask you this. Earlier when I asked you to do some imagining, if anyone feels comfortable sharing, I kind of want to hear, you know, before and now after hearing all of this, imagine sort of that not-so-good work experience. If anyone feels comfortable with sharing, I mean, what was that like? Or what were the things that you felt could have been better or that need to, you know, that people can really work on in these spaces? Anybody feel comfortable to share? Thank you. So I was probably putting out a fellowship for about ten years and got into a new job. And I had a three-year contract from a fairly massive organization. And about a year and a half into it, one of the people came up and said, hey, we gave you a three-year contract, we're only supposed to give you a two-year contract. Oh, wow. Okay. We'll pay you too much money. We're going to take your vacation time and we're going to cut your salary by 25%. And, I mean, there's no way purely a little doctor is going to apply that multi, multi, multi-billion-dollar health care. And so, you know, I was like, what just happened? It's like I didn't give myself the contract. So all of these things. I'm seeing Brian has a microphone. Do you have a microphone? Okay, thank you. Sorry. Oh, it won't. This is anonymous, like our tool, our feedback box. So, basically, one of our audience members was sharing, you know, that they go ahead. So, yeah, my experience was with a company that, in the middle of a contract, they came back and said, you know, we've given you too much money, we're giving you too much money. We've got, you know, you're getting too much vacation. I mean, I wasn't getting a bonus, but they were going to cut that also. So, anyway, the next day I started looking for a job. But the CFO of the company came and told me, and he said, hey, I'm really sorry. This is really bad. We shouldn't do this kind of stuff. And so they honored the three-year contract. They still cut my salary and my vacation time. But, you know, I was very happy to leave. So fast forward about eight months after I left the place. They came and asked me, can you do MRO services for me? Because this was the office manager. And I said, sure, I'll help you out. And I said, okay, fine. And how much do you want? I said, you say. So she's like, I'll give you $50 for MRO services per MRO. I said, okay, fine. And they're giving me $300 a month or something like that. So the first person that came and told me we're paying you too much money, his wife also works there. His wife came and told me about six months into this, we're paying you too much money for the MRO services. You know, once bitten, twice shy kind of a thing. And so I said, you guys, so they said, well, we'll double your volume and decrease your pay by half. This was before COVID? Yes. Oh, wait a minute. So we'll double your volume, decrease for your MRO services. So, you know, I think like I'm the idiot who did this. But the second time I did this as a favor to my friend. But, you know, it's a very painful situation. And as a professional, you go through that. You know, but this is happening, I think, to what you guys are saying. This is happening to people who just don't have that ability even to say something to their own supervisor. Who don't have that power. I had that feeling because I was dealing with a multi-billion dollar corporation. I mean, their lawyers made more in half a day than I made in a year probably. You know, so anyway. Yeah, I was just going to share. You're exactly right. And those stories get left untold. Right. But those stories were, to your point, stories that were shared in that open free text feedback box. That those difficult conversations that me and the CEO had. And saying that, hey, we need to address some of these things. We're able to get addressed. And I think intentionally, Ro and I were talking about this before we came down. The way organizations are structured with the highest levels of leadership. Not being able to communicate or know who the people are that do the services and things like that. It makes it very difficult to fix or remedy a lot of those issues. When there's so many layers you have to get past. And that's a driver of burnout. Right. One more thing. I'll just follow up real quick. So this job that I took, actually, I purely did it for the medical director designation and increase in salary. And, you know, I've never chased a job for money. I've never chased a job for a title. And this was the only one that I did that with. And it got me. So every other one, I've just done it with the feel of the people, how we've interviewed, how we've done all the other things. And I think that should give you a lot more information, just having that camaraderie and that openness you have. I think that makes a huge difference. Thank you for sharing. Thank you for being vulnerable and for feeling safe enough to share that with us all. And obviously you heard those themes, right? I heard themes of lack of fairness, lack of recognition or reward, values mismatch, perceived lack of control. It sounds like you hit all the colors in the rainbow for this, for causes of burnout, of organizational factors. We have a few minutes left. And I'd like to end on a positive note. If anybody would like to share a good job, best job, best day, best week at work and why that was, what it did. It was my boss from my best job. That's your boss from your best job. Nice. Actually, a different thing, which is that now I'm at Case Western Reserve doing some facilitating with first-year med students. And just two weeks ago they had a session on trauma-informed care for the first-year med students talking about that. And I think it needs to be in every med school. And medical students, residents need to be trained. And I also think, you know, they were talking about refugee care because there's a lot of refugees in the Cleveland area. And the HRSA clinic there sees most of them. But I think, and the pandemic obviously is the other one. And then climate change. Yesterday we were talking about the mental health issues around climate change. And it's only going to get worse, you know? So every practitioner, physician, nurse practitioner, PAs, I think, needs to know this stuff. All I can say is thank you. I can't add anything. That was perfect. Thank you so much, Dr. Fagan. All right. Thank you. We do know math. That was a comment. All right. Thank you so much. Thank you. And enjoy the rest of the conference. We'll see you around.

Refilling Our Cups

Total Worker Health Systems Level Programs

Community Health Center Staff Well-Being

Access Health

Healthcare Access

Well-Being Programs

Employee Well-Being

Organizational Change

Trauma-Informed Care